How do you diagnose and manage Sever's disease?

Diagnosing and Managing Sever's Disease

Sever's disease (calcaneal apophysitis) is primarily a clinical diagnosis that can be confirmed through specific physical examination tests, with no need for radiographic confirmation in typical cases. 1

Diagnostic Approach

Clinical Presentation

• Occurs in children and adolescents, often during growth spurts
• Commonly affects young athletes in running and jumping sports (particularly soccer)
• Presents with intermittent or continuous heel pain that worsens with weight-bearing activities 2
• Can be unilateral or bilateral 3

Physical Examination Tests (100% specificity)

1. One-leg heel standing test (100% sensitivity): Ask the child to stand on the affected heel; positive if pain is reproduced 1
2. Squeeze test (97% sensitivity): Apply medial-lateral compression to the posterior calcaneus; positive if pain is elicited 1
3. Palpation test (80% sensitivity): Direct palpation of the calcaneal apophysis; positive if tenderness is present 1

Additional Clinical Findings

• Tight heel cords/Achilles tendon 2
• Pain worsens with activity and improves with rest
• Mild swelling may be present at the posterior heel 3

Management Protocol

First-Line Treatment

1. Rest: Reduce or modify activities that cause pain
2. Ice application: Apply to the affected heel for 15-20 minutes, 2-3 times daily 2
3. Heel lifts: Use in both shoes to reduce tension on the Achilles tendon 2

Physical Therapy Interventions

1. Stretching exercises: Focus on Achilles tendon and plantar fascia
2. Strengthening exercises: For foot and ankle muscles
3. Kinesiotherapy: Supervised exercise programs 3, 4

Orthotic Devices

• Foot orthoses/insoles: Provide shock absorption and reduce stress on the calcaneal apophysis 4
• Kinesio taping: May provide symptomatic relief 4

Pharmacological Management

• NSAIDs: Consider in more severe cases for pain and inflammation control 2

Expected Outcomes and Follow-up

• Resolution typically occurs within 2 weeks to 2 months after initiating conservative treatment 2
• The condition is self-limiting but may recur during growth spurts
• No radiographic follow-up is needed in typical cases

Important Considerations

When to Consider Imaging

• Atypical presentation or failure to respond to conservative treatment
• MRI should be considered in cases with:
  • Severe or persistent pain despite treatment
  • Systemic symptoms (fever)
  • Significant swelling or erythema
  • To rule out rare complications such as osteomyelitis 5

Prevention Strategies

• Education of parents, coaches, and young athletes about proper footwear
• Gradual increase in training intensity, especially at the start of sports seasons
• Regular stretching of the Achilles tendon and calf muscles
• Avoiding excessive running on hard surfaces

Red Flags Requiring Further Investigation

• Fever or systemic symptoms
• Night pain unrelated to activity
• Significant swelling, redness, or warmth
• Failure to improve with conservative management after 2 months

Remember that Sever's disease is a clinical diagnosis that does not require radiographic confirmation. Radiographic findings such as increased density and fragmentation of the calcaneal apophysis can be found in both symptomatic patients and asymptomatic controls with high physical activity levels 1.